Grundy Care Center

on the camera at 3:32:05 PM just prior to crossing the street to the hospital parking lot.

Staff A had come in contact with the resident at 3:33:33 PM and began walking her back to the facility.

The facility corrected the deficiency prior to the start of the survey on 8/27/25 by implementing the following: a. Resident #1 placed on 1:1 staff supervision immediately upon returning to the facility. Resident #1 continued on 1:1 supervision until transferred to another facility with a locked unit on 10/2/25. b.

Physician and the responsible party were notified of findings. No new orders given.c.

Head to toe assessment completed on resident.

Assessment within normal limits for residentd.

Sign placed on back door and checked for placement on all other doors to remind staff, visitors, or contractors to look behind them when exiting and not to let residents out the door unsupervised.e.

Staff educated immediately regarding elopement on 08/26/25.f.

Resident Council held 8/27/25 to educate residents on elopement and the importance of keeping all residents safe.g.

Elopement reviewed at the Quality Assurance and Performance Improvement (QAPI) meeting.h. Resident #1's plan of care was reviewed to ensure interventions in place to prevent future elopements.i.

Additional staff and alert and oriented resident interviews completed.j.

Process started to find resident placement in a locked dementia unit due to the fact that Resident #1 won't wear a wander guard and removes the wander guard as soon as it is placed.

The wander guard had actually caused the resident to have behaviors when she was wearing it and stated, I feel like a prisoner.k.

Will continue elopement drills in the facility to ensure employee compliance.

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